Green Hills Center: Insulin Given in Public Dining Room - OH
The incident occurred at 11:22 a.m. on September 8, when Registered Nurse #360 approached Resident #39, who was sitting at a table in the facility's dining room. The nurse informed the resident she had insulin to administer, then proceeded to lift the resident's shirt and inject insulin into the resident's abdomen while others remained seated at the same table.
The resident, admitted in August 2022, has type two diabetes, dementia, and major depressive disorder. A recent assessment revealed the resident had moderate cognitive impairment.
The nurse administered the injection without gloves and failed to perform hand hygiene beforehand, inspectors documented. When interviewed immediately after the incident at 11:23 a.m., the nurse acknowledged giving insulin in the dining room with other residents present at the table.
"She should have pulled the resident away from the table before administering the insulin," the nurse told inspectors. She also acknowledged she should have worn gloves during the procedure.
The facility's own policy on subcutaneous injections, revised in May 2025, requires nurses to provide privacy and explain procedures to patients. The policy also mandates hand hygiene and positioning patients while exposing injection sites appropriately.
Regarding gloves, the facility policy states they should be worn "if contact with blood or bodily fluids is likely or if your skin or the patient's skin isn't intact," though it notes gloves "are not required for routine subcutaneous injections because they do not protect against needlestick injury."
The violation occurred just days before inspectors arrived. On September 8, following the dining room observation, facility physicians issued new orders specifically addressing the incident. The orders, initiated that same day, indicated staff "may give medications, check blood sugar and give insulin in public spaces and dining room."
The timing suggests the facility attempted to retroactively authorize the practice after it had already occurred and been observed by inspectors.
Federal regulators cited the facility for failing to ensure resident dignity during medical procedures. The violation affected one resident out of 67 total residents at the facility during the September inspection.
The incident represents a fundamental breach of nursing home standards that require facilities to protect residents' dignity during intimate medical procedures. Insulin injections typically require exposing the abdomen, thigh, or arm, making privacy particularly important.
For Resident #39, who lives with dementia and moderate cognitive impairment, the public administration of medication compounded the dignity violation. Residents with cognitive impairments may be less able to advocate for themselves or understand when their privacy rights are being violated.
The complaint investigation that uncovered this violation was numbered 2601174, indicating it originated from a specific complaint filed with state regulators.
Green Hills Center, located at 6557 US 68 South in West Liberty, operates as a 67-bed nursing facility. The September inspection focused specifically on this complaint rather than a comprehensive annual survey.
The facility's policy clearly outlined proper procedures that the nurse failed to follow. Beyond the privacy requirements, the nurse's failure to perform hand hygiene before the injection created additional infection control risks for the resident.
The incident occurred in one of the facility's most public spaces, where residents typically gather for meals and social activities. Having medical procedures performed in such settings undermines the homelike environment nursing facilities are required to maintain.
Federal regulations require nursing homes to treat residents with dignity and respect their right to privacy during medical care. The regulation cited, F 0550, specifically addresses residents' rights to "dignified existence, self-determination, communication, and to exercise his or her rights."
The violation was classified as causing "minimal harm or potential for actual harm" affecting "few" residents. However, dignity violations can have lasting psychological impacts on residents, particularly those with cognitive impairments who may not fully understand what occurred.
Resident #39 continues living at Green Hills Center, where staff now operate under the new physician orders that appear to authorize medication administration in public areas. Whether these orders adequately address the underlying dignity concerns remains unclear from the inspection record.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Green Hills Center from 2025-09-11 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
GREEN HILLS CENTER in WEST LIBERTY, OH was cited for violations during a health inspection on September 11, 2025.
The incident occurred at 11:22 a.m.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.